non-traumatic pulseless electrical activity arrest. The study was limited as only 13/39 patients (33%) underwent radiography in the emergency department before ...
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From the prehospital literature Malcolm Woollard Emerg. Med. J. 2008;25;606 doi:10.1136/emj.2008.063842
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From the prehospital literature Edited by Malcolm Woollard
Prehospital CPAP: should we pause to catch our breath? Continuous positive airway pressure (CPAP) improves outcome in acute cardiogenic pulmonary oedema (ACPO) and is increasingly available in emergency departments. In theory, reducing delay to starting CPAP could benefit patients by helping to re-establish haemodynamic stability, but it is not known whether equipping ambulances and training staff in this technique is safe and both clinically and cost effective. Plaisance and colleagues from Paris conducted a randomised trial of 124 patients in the two-tier emergency medical system involving fire rescue personnel and anaesthetists or emergency physicians, together with an anaesthetic nurse, driver and medical student. Patients with ACPO who remained hypoxic despite high-flow oxygen were randomised to early or late CPAP, with the early group receiving ‘‘standard’’ medical treatment (intravenous diuretic, nitrate and nicardipine) before CPAP was applied. Inotropic support was added at the discretion of the attending doctor. While the authors conclude that prehospital CPAP provided within 15 min of management is superior to ‘‘standard’’ medical therapy, there are several reasons why the study findings are unlikely to be directly generalisable to UK practice: doctors are rare in the UK prehospital setting, as are the additional personnel reported here, and the range of medicines exceed those provided by paramedics. A randomised trial assessing the safety and effectiveness of CPAP in the UK prehospital setting is planned, and not before time.
S Christopher, College of Paramedics Research and Audit Committee Flynn J, Archer F, Morgan A. Sensitivity and specificity of the medical priority dispatch system in detecting cardiac arrest calls in Melbourne. Prehosp Disast Med 2006;21:72–6. c
Scaling the barriers to improved response times This observational study explored the emergency medical services (EMS) time component from arrival on scene to arrival at the patient’s side in an urban setting where different types of buildings can result in barriers to access. Observers riding with EMS crews in New York City recorded different time components for 449 emergency calls. The median time from ambulance dispatch to arrival on scene was 5.2 min and the median time from arrival on scene to patient side was 2.1 min. The arrival on scene to patient time varied for different types of location, ranging from 2.7 min for high rise residential buildings, 1.3 min for private homes or residential buildings with three storeys or less, to 0.5 min for outdoor calls. The most frequently encountered barriers were incorrect addresses and apartment numbers and locked doors. On-site bystanders providing help in locating patients reduced the time taken to reach the patient’s side by 20%. EMS performance is measured by the response time interval from dispatch to arrival on scene, but this study shows that the additional time taken to locate patients adds 28% to the response time interval from dispatch to arrival at the patient’s side.
J Turner, College of Paramedics Research and Audit Committee Silverman R, Galea S, Blaney S, et al. The ‘‘vertical response time’’: barriers to ambulance response in an urban area. Acad Emerg Med 2007;14:772–8. c
T Quinn, College of Paramedics Research and Audit Committee Plaisance P, Pirracchio R, Berton C, et al. A randomized study of out-of-hospital continuous positive airway pressure for acute cardiogenic pulmonary oedema: physiological and clinical effects. Eur Heart J 2007;28:2895–901. c
Diagnosing death on the line This retrospective study aimed to ascertain the accuracy with which the medical priority dispatch system (MPDS) identifies cases of cardiac arrest. Ambulance dispatch records of all cases suspected as cardiac arrest over a 3-month period were matched with ambulance patient records and those from the Victorian Ambulance Cardiac Arrest Registry to determine the number of correctly identified cardiac arrests. Although 76.7% of cardiac arrests were correctly identified, it was found that 172 of these were allocated a nonpriority MPDS code so were allocated fewer resources than necessary. Additionally, of those cases identified as potential cardiac arrests, only 58.2% turned out to be so. This resulted in 41.8% of these calls being allocated unnecessary resources. This is an important finding as it is not only cardiac arrests that are life-threatening. The results therefore show that valuable resources may be wrongly directed to such calls when they might be better employed elsewhere. This can be illustrated by considering that the Lincolnshire Division of East Midlands Ambulance Service routinely allocates two vehicles to calls identified as cardiac arrest. This study highlights the fact that further research would be of value in this area in order to improve the sensitivity of the MPDS system.
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Paramedics relieve tension The authors of this retrospective review examined the records of patients treated with needle thoracocentesis (NT) by paramedics in a single ambulance service and delivered to the same level 1 trauma centre over a 1-year period. The proportion of advanced life support patients requiring NT was 39/20 330 (0.2%), of which 22/39 (56.4%) were in circulatory arrest, with 12 suffering traumatic arrest and 10 in non-traumatic pulseless electrical activity arrest. The study was limited as only 13/39 patients (33%) underwent radiography in the emergency department before placement of a formal chest tube. Of these, 4/13 (30.8%) had evidence of an incompletely decompressed pneumothorax. Two of the 13 patients who underwent radiography had no evidence of pneumothorax and one had ipsilateral aspiration. Of the 31 patients transported directly to the level 1 trauma centre, the NT was considered to be correctly placed in all and there were no complications reported by emergency physicians. The authors identified four cases of unexpected survival which they linked to the provision of prehospital NT. Although the results of this trial are not directly generalisable to the UK (paramedics in this study obtained online physician approval to perform NT and used a 12gauge 5 cm needle), it provides limited evidence that NT—while being an infrequently used skill—is safe and effective in the hands of appropriately trained paramedics.
M Woollard, College of Paramedics Research and Audit Committee Warner KJ, Copass MK, Bulger EM. Paramedic use of needle thoracostomy in the prehospital environment. Prehosp Emerg Care 2008;12:162–8. c
Emerg Med J September 2008 Vol 25 No 9
